People with Diabetes Focus on Different Complications than Clinicians

Clinicians treating those with diabetes are most often focused on managing blood sugar and warning against potential complications, such as retinopathy, neuropathy and foot ulcers.

Rightfully so, said a panel of experts presenting at the American Diabetes Association 77th scientific sessions in San Diego, California, but growing evidence suggests that urologic and sexual complications may be more prevalent and of greater concern to patients, necessitating greater attention from endocrinologists.1

Basic Quality of Life Concerns Matter More

"These conditions don't carry the risk of mortality that the more worrisome complications do, but these are conditions that matter most to patients because they are bothersome," said Aruna V. Sarma, PhD, MHA associate professor of urology and epidemiology at the University of Michigan in Ann Arbor, presenting during the session on Urological complications and sexual dysfunction in diabetes.

So troublesome to our patients, Dr. Sarma said, that the urologic and sexual problems take a greater toll on daily living, much more so, than the complications thought of as more directly related to their diabetes.2 And, the complications affecte the quality of life (QoL) for those with diabetes more than those without, she said.

In The Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications (DCCT/EDIC) Cohort trial,2 assessing the urologic complications and the relationship to the health-related QoL in more than 1200 men and women with type 1 diabetes (T1D), the odds of a low daily QOL score (25th percentile or less) was 3 times greater in men with erectile dysfunction (ED) and 2.65 times greater in those with lower urinary tract symptoms as compared to individuals who didn’t have diabetes, and, for women, the odds of a low score were 2 times greater with sexual dysfunction and 2.71 times greater with UIs or LUTS compared to men and women without the complications.2

In effect, sexual ease and bladder control had a more negative overall impact on patients' lives, than did retinopathy and neuropathy.

"The World Health Organization argues that sexual health is a basic human right," said panelist Hunter Wessells, MD, FACS, professor, and chair of urology and the Nelson-Endowed Chair, University of Washington. Yet, among the those with diabetes, Dr. Wessells said, "50% of men with have ED by the age of 50,'' he says. "Is that normal? " Absolutely not, he said. " Citing National Health and Nutrition Examination Survey data,3 Dr. Wessells noted that ''you don't get to the 50% rate in the general population until they are in their 70s."

Women with diabetes tend to report a lack of sexual desire and urinary incontinence as the primary issues negatively affecting their QoL, said Dr. Sarma. Her research2 and that of others4,5 suggests that ''the burden of these [complications] is greater in those with diabetes and their diabetes affects the complications."

Other research has shown that 50% of patients with diabetes had experienced problems with overactive bladder,1 said Michael Albo, MD, professor of urology at the University of California at San Diego. Among the most common symptoms were nocturia, frequency, hesitancy, reduced stream and incomplete emptying, he said. Often, these symptoms don’t get recognized early enough, Dr. Albo said, partly due to insidious onset.

Adverse Effects of Diabetes on Underlying Complications

Prolonged hyperglycemia can cause dysfunction of the urethral sphincter, according to Dr. Albo. Historically, lower urinary tract symptoms (LUTS) in men have been linked with bladder outlet obstruction secondary to BPH. However, not all men with benign prostatic hyperplasia (BPH) have LUTS and not all men with LUTS have BPH, he said.

“While LUTS may be prevalent in both sexes, women complain more of storage symptoms whereas men are more bothered by voiding symptoms,” Dr. Albo said, “There is a possible link between LUTS and type 2 diabetes in men.”

"The longer [patients] have diabetes, the more likely [they] are to have bladder dysfunction," he said, and urinary incontinence has been linked with the level of glycemic control in T1D but not in people with type 2 diabetes.

Role for Endocrinologists in Addressing Patient Complaints

"We definitely have solutions for these men [with ED]," Dr. Wessells said. “Phosphodiesterase type 5 inhibitor (PDE5) inhibitors work, but men with diabetes may also want to try the remedies often considered as second or third line therapies—vacuum erection devices, intracavernosal injection therapy and penile prostheses.”

For women wanting to boost their libido, the choices are much more limited, he said. The FDA has approved only one medicine, flibanserin, for low desire. And now it has a contraindication warning against drinking alcohol while taking this medication, which reduces the options for women further.

Lifestyle measures may provide the best solution to overcome sexual problems, Dr. Wessells said. Endocrinologists should intervene at the first sign of ED in men, recommending better glucose control, committing to a regular exercise routine, losing weight if needed, and stopping cigarette smoking, he recommended.

Good blood glucose control may help patients reverse urologic problems since incontinence, for example, has been linked with the level of glycemic control,1,6 said Dr. Albo.

A Clinician's Take on Patients' Priorities

The statistics about urologic and sexual problems impacting the QoL more than the diabetes-related complications of neuropathy and retinopathy are not a surprise, Elena A. Christofides, MD, FACE, CEO of Endocrinology Associates, Inc., in Columbus, Ohio, told EndocrineWeb.

''If a patient has a couple episodes of hypoglycemia in a week, it may knock them out of sexual intercourse for three or four days," she said., "That has a significant effect on their day to day lives."

Good blood glucose control is the first measure, she said, but she also urged physicians not to be afraid to bring up the more personal topics with their patients. She often broaches the subject of sexual and urologic issues in the first visit, and then finds patients much more relaxed and willing to talk about it when returning for follow-up visits. In effect, endocrinologists need to set the tone and make patients feel comfortable discussing otherwise embarrassing topics so the patient will bring up it should it become a problem.

Unanswered Questions, Looking Ahead

Patterns of sexual problems seem to differ in men with type 2 versus type 1 diabetes, Dr. Wessells said, indicative that we still need more information.

“What is also needed,” he said, “is a risk stratification for sexual complaints and interventions targeted to specific pathophysiologies.”

Jacobson AM, Braffett BH, Cleary PA, Dunn RL, Larkin ME, Wessells H, Sarma AV, for the DCCT/EDIC Research Group. Relationship of Urologic Complications With Health-Related Quality of Life and Perceived Value of Health in Men and Women With Type 1 Diabetes: The Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications (DCCT/EDIC) Cohort. Diabetes Care. 2015; 38(10):1904-1912. https://doi.org/10.2337/dc15-0286

CDC/NCHS. National Health and Nutrition Examination Survey (NHANES). Diabetes prevalence and glycemic control among adults aged 20 and over, by sex, age, and race and Hispanic origin: United States, selected years 1988–1994 through 2011–2014. Table 40. Available at: https://www.cdc.gov/nchs/data/hus/2015/040.pdf.